With so many resources available to the general public about health care, physicians now encounter patients armed with a lot of information, a little information, and the wrong information.

Take the dilemma many new parents face when it comes to vaccination schedules for their babies.

“More parents are refusing or delaying children’s vaccinations,” said Dr. Michael Sia, a

Honolulu pediatrician. “Many parents complain that the recommended schedule of shots is too much. They have questions: Do they work? Will they cause autism? Will they cause side effects?”

Despite physicians’ busy schedules, it’s important to take the time to talk to parents.

“It’s really key for pediatricians to be the flag wavers when it comes to giving parents information that is reliable, complete and science-based,” Sia said. “A lot of parents

will go to the Internet for information, read blog sites of experts, but not necessarily sites that the medical community would rely upon.”

Sia recommends that physicians be ready for the rapid-fire line of parental questioning by sharing with them information from such websites as the American Academy of Pediatrics (www.aap.org), the Centers for Disease Control and Prevention (www.cdc.gov), and the American Academy of Family Physicians (www.aafp.org). These sites provide reassuring information about the immunization schedule for parents who are afraid for their children’s welfare. From the CDC site, pediatricians and parents can print a PDF copy of its Parents’ Guide to Child Immunizations (www.cdc.gov/vaccines/pubs/parents-guide/default.htm).

The schedule is based on two premises: the age when a body’s immune system works the best, balanced with the need to provide protection at the earliest possible age. And that, Sia said, is based strictly upon scientific findings.

HM

SA

’s

For Participating medical practitioners September 2010

Physician FocusWhen parents ask about keiki immunizations

Hawaii Medical Service Association

818 Keeaumoku St.

P.O. Box 860

Honolulu, HI 96808-0860

Phone: (808) 948-5110

Branch offices

located on

Hawaii, Kauai and Maui

Internet address:

www.hmsa.com

Provider Resource Center:

hhin.hmsa.com

(Continued on page 2)

“Vaccines are the most successful and cost-effective public health tool available to prevent disease and death,” Sia said. “People have to realize vaccines don’t just protect individuals. They also protect communities.”

Skeptical parents, however, might still believe that the schedule of vaccines is too overwhelming for baby. But by the time they turn 2, a child will have been provided some 150 antigens against the 15 diseases on the schedule. These are identified as life threatening and/or debilitating.

“But what happens when your kid gets a cold?” Sia asks. “About 2,000 to 6,000 little antigens are present when a child has a common cold. The combination of shots, the antigens that we give from 0 to 6 years of age, does not over whelm a child’s system.”

Sia knows all too well the demands of a pediatrician’s schedule. Despite that, he recommends a few minutes of face time to dispel parents’ fears. But how does a pediatrician reach the parents who will not bring

their children to the doctor’s office? Public service announcements and a steady stream of positive messages through various media outlets can help spread the word, Sia said.

“We need to be thinking more as a community, not just as ourselves as individuals,” Sia said. “Vaccinations are the best way to prevent the spread of diseases. It’s cost effective, saves time off from work to care for our sick children, and it keeps people healthy and out of the hospital. Parents should be informed of the firmly scientific evidence in support of immunizations.”

Use science-based evidence for the ‘shot talk’

“About 2,000 to 6,000 little antigens are present when a child has a common cold ...”

This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory

Committee on Immunization Practices statement for detailed recommendations: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by telephone, 800-822-7967.

1. Hepatitis B vaccine (HepB). (Minimum age: birth)At birth:•AdministermonovalentHepBtoallnewbornsbeforehospitaldischarge.• IfmotherishepatitisBsurfaceantigen(HBsAg)-positive,administerHepBand0.5mLofhepatitisBimmuneglobulin(HBIG)within12hoursofbirth.

• Ifmother’sHBsAgstatus isunknown,administerHepBwithin12hoursofbirth.Determinemother’sHBsAgstatusassoonaspossibleand,ifHBsAg-positive,administerHBIG(nolaterthanage1week).

After the birth dose:•TheHepBseriesshouldbecompletedwitheithermonovalentHepBoracom-binationvaccinecontainingHepB.Theseconddoseshouldbeadministeredatage1or2months.MonovalentHepBvaccineshouldbeusedfordosesadministeredbeforeage6weeks.Thefinaldoseshouldbeadministerednoearlierthanage24weeks.

• Infants born toHBsAg-positivemothers should be tested forHBsAgandantibodytoHBsAg1to2monthsaftercompletionofatleast3dosesoftheHepBseries,atage9through18months(generallyat thenextwell-childvisit).

•Administrationof4dosesofHepBtoinfantsispermissiblewhenacombina-tionvaccinecontainingHepBisadministeredafterthebirthdose.Thefourthdoseshouldbeadministerednoearlierthanage24weeks.

2. Rotavirus vaccine (RV).(Minimumage:6weeks)•Administer the first doseat age6 through14weeks (maximumage:14weeks6days).Vaccinationshouldnotbeinitiatedforinfantsaged15weeks0 days or older.

•Themaximumageforthefinaldoseintheseriesis8months0days• IfRotarixisadministeredatages2and4months,adoseat6monthsisnot

indicated.3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP).

(Minimumage:6weeks)•Thefourthdosemaybeadministeredasearlyasage12months,provided

at least 6 months have elapsed since the third dose.•Administerthefinaldoseintheseriesatage4through6years.

4. Haemophilus influenzae type b conjugate vaccine (Hib).(Minimumage:6weeks)• IfPRP-OMP(PedvaxHIBorComvax[HepB-Hib])isadministeredatages2

and 4 months, a dose at age 6 months is not indicated.•TriHiBit(DTaP/Hib)andHiberix(PRP-T)shouldnotbeusedfordosesatages

2, 4, or 6 months for the primary series but can be used as the final dose in children aged 12 months through 4 years.

5. Pneumococcal vaccine. (Minimumage:6weeksforpneumococcalconjugatevaccine[PCV];2yearsforpneumococcalpolysaccharidevaccine[PPSV])•PCVisrecommendedforallchildrenagedyoungerthan5years.Administer

1 dose of PCV to all healthy children aged 24 through 59 months who are not completely vaccinated for their age.

•AdministerPPSV2ormoremonthsafterlastdoseofPCVtochildrenaged2years or older with certain underlying medical conditions, including a cochlear implant. See MMWR1997;46(No.RR-8).

6. Inactivated poliovirus vaccine (IPV) (Minimumage:6weeks)•Thefinaldose in theseriesshouldbeadministeredonorafter the fourth

birthday and at least 6 months following the previous dose.• If4dosesareadministeredpriortoage4yearsafifthdoseshouldbeadmin-

istered at age 4 through 6 years. See MMWR2009;58(30):829–30.7. Influenza vaccine (seasonal). (Minimum age: 6 months for trivalent inacti-

vatedinfluenzavaccine[TIV];2yearsforlive,attenuatedinfluenzavaccine[LAIV])•Administerannuallytochildrenaged6monthsthrough18years.•Forhealthychildrenaged2through6years(i.e.,thosewhodonothaveunder-

lying medical conditions that predispose them to influenza complications), eitherLAIVorTIVmaybeused,exceptLAIVshouldnotbegiventochildrenaged 2 through 4 years who have had wheezing in the past 12 months.

•ChildrenreceivingTIVshouldreceive0.25mLifaged6through35monthsor0.5mLifaged3yearsorolder.

•Administer2doses(separatedbyatleast4weeks)tochildrenagedyoungerthan 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose.

•ForrecommendationsforuseofinfluenzaA(H1N1)2009monovalentvaccinesee MMWR2009;58(No.RR-10).

8. Measles, mumps, and rubella vaccine (MMR). (Minimum age: 12 months)•Administertheseconddoseroutinelyatage4through6years.However,theseconddosemaybeadministeredbeforeage4,providedatleast28dayshave elapsed since the first dose.

9. Varicella vaccine. (Minimum age: 12 months) •Administertheseconddoseroutinelyatage4through6years.However,theseconddosemaybeadministeredbeforeage4,providedatleast3monthshave elapsed since the first dose.

•Forchildrenaged12monthsthrough12yearstheminimumintervalbetweendosesis3months.However,iftheseconddosewasadministeredatleast28daysafterthefirstdose,itcanbeacceptedasvalid.

10. Hepatitis A vaccine (HepA). (Minimum age: 12 months)•Administer to all childrenaged1 year (i.e., aged12 through23months).

Administer 2 doses at least 6 months apart.•Childrennotfullyvaccinatedbyage2yearscanbevaccinatedatsubsequent

visits•HepAalsoisrecommendedforolderchildrenwholiveinareaswherevac-cinationprogramstargetolderchildren,whoareatincreasedriskforinfection,or for whom immunity against hepatitis A is desired.

11. Meningococcal vaccine. (Minimum age: 2 years for meningococcal conjugate vaccine[MCV4]andformeningococcalpolysaccharidevaccine[MPSV4])•AdministerMCV4tochildrenaged2through10yearswithpersistentcomple-

ment component deficiency, anatomic or functional asplenia, and certain other conditionsplacingthamathighrisk.

•AdministerMCV4 tochildrenpreviouslyvaccinatedwithMCV4orMPSV4after3yearsiffirstdoseadministeredatage2through6years.SeeMMWR 2009;58:1042–3.

Range of recommended ages for certain high-riskgroups

Range of recommended ages for all childrenexceptcertainhigh-riskgroups

Vaccine ▼ Age ► Birth1

month2

months4

months6

months12

months15

months18

months19–23

months2–3

years4–6

years

HepatitisB HepB

Rotavirus RV RV RV

Diphtheria, Tetanus, Pertussis DTaP DTaP DTaP

Haemophilus influenzae type b Hib Hib Hib

Pneumococcal PCV PCV PCV

Inactivated Poliovirus IPV IPV

Influenza

Measles, Mumps, Rubella

Varicella

HepatitisA

Meningococcal

HepBHepB

DTaP DTaP

Hib

IPVIPV

MMR

VaricellaVaricella

MMR

PCV

HepA Series

MCV

Influenza (Yearly)

PPSV

HepA (2 doses)

Recommended Immunization Schedule for Persons Aged 0 Through 6 Years—United States • 2010Forthosewhofallbehindorstartlate,seethecatch-upschedule

CS20

7330

-A TheRecommendedImmunizationSchedulesforPersonsAged0through18YearsareapprovedbytheAdvisoryCommitteeonImmunizationPractices(http://www.cdc.gov/vaccines/recs/acip), the American Academy of Pediatrics (http://www.aap.org),andtheAmericanAcademyofFamilyPhysicians(http://www.aafp.org).

DepartmentofHealthandHumanServices•CentersforDiseaseControlandPrevention

Recommended immunization schedule for children ages 0-6 years

(From page 1)

2 ♦ PhysicianFocus September2010

Source: Department of Health and Human Services Centers for Disease Control and Prevention.See www.cdc.gov/vaccines/recs/schedules for printable immunization schedules and complete footnotes.

Well-baby and well-child visits are important to monitor a child’s development and growth. HMSA covers well-child and well-baby visits for most plans. For detailed benefit information, please visit: hmsa.com/portal/provider/zav_pel .ph.WEL.500.htm.

Well-baby & well-child visits

3 ♦ PhysicianFocus September2010

Vaccines are not just for infants, but many adolescents do not receive their recommended immunizations on time. The ACIP recommends the following immunizations by age 13: meningococcal (1 dose), Tdap (1 dose), HPV (3 doses), and influenza (annually). Vaccines are safe, effective, and a covered benefit of most HMSA health plans.

Adolescent immunizations

To assist physicians, HMSA provides various resources to target increased immunizations. Available are brochures for members that rebut common myths and educate parents on the types of vaccines recommended, and reminder cards that physicians can send to parents reminding them of immunization due dates or to call to make an appointment.

HMSA also provides physicians with a list of their HMO and QUEST members turning 2 years old. A quick reference guide provides office staff with billing information for immunizations. HMSA staff are also available to meet with physicians to discuss their concerns or questions regarding immunizations.

For information on obtaining immunization resources, please call HMSA’s Provider Relations and Advocacy unit at 948-5190 on Oahu or toll-free at 1 (800) 603-4672, ext. 5190, on the Neighbor Islands to schedule a meeting or to request additional material.

HMSA resources for physicians

To achieve accreditation, a health plan is assessed on a wide range of quality measures, including preventive care and management of chronic diseases. Based on evidence-based medicine, some of these have become clinical quality measures for HMSA’s Practitioner Quality and Service Recognition (PQSR) program and our Quality and Performance (Q&P) program.

Here are health plan measures that relate to services for children and adolescents: • Providing strep tests to children with

a single diagnosis of pharyngitis and an antibiotic prescription within three

days. ICD 9 codes for pharyngitis: 462, 463, 034.0.

• Children ages 3 months to 18 years with an upper respiratory infection (URI) diagnosis that were not dispensed an antibiotic prescription within three days. ICD 9 codes for URI: 460, 465.

• CDC recommended immunizations provided before a child’s second birthday.

• Prescribing a long-term asthma controller therapy to members age 5 or older identified as being persistent asthmatics. ICD 9 code for asthma: 493.

Understanding Quality Measures

September20104 ♦ PhysicianFocus

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